History
The nurses in the intensive care unit contact you regarding a 70-year-old postoperative male who had a hip replacement 24 hours previously. The man is extremely agitated and keeps wanting to pull out his intravenous line and get out of bed. He is quite fragile and there is real concern that he may get physically hurt if he is not restrained. He is demanding to be allowed to leave and go home. The nurses want to know whose responsibility it is to ‘section’ him to ensure that he can be treated.
Mental state examination
The man is uncooperative and does not answer questions. He just repeats his demands to be allowed to leave. His speech is loud and repetitive. There is no evidence of psychosis. The man cannot tell you the year, season, date, day or month. He can tell you he is in hospital but cannot understand why. He cannot register any information and immediately forgets why he cannot go home even when this is explained to him.
Physical examination
The man is clearly agitated and hostile when he is spoken to. He is connected to an IV drip and looks well-hydrated. He is apyrexial. There is a bandage on his right leg with a drain. There does not seem to be any excessive bleeding. The man denies begin in any pain.
Normal Haemoglobin 14.4 g/dL 13.3–17.7 g/dL Mean corpuscular volume (MCV) 85 fL 80–99 fL White cell count 8.8 × 109/L 3.9–11.0 × 109/L
Platelets 280 × 109/L 150–440 × 109/L
Sodium 139 mmol/L 135–145 mmol/L
Potassium 3.5 mmol/L 3.5–5.0 mmol/l
Urea 2.9 mmol/L 2.5–6.7 mmol/L
Creatinine 75 μmol/L 70–120 μmol/L Blood glucose 6 mmol/L 4–6 mmol/L Alkaline phosphatase 151 IU/L 30–300 IU/L Alanine aminotransferase 26 IU/L 5–35 IU/L
ANSWER 69
Some degree of postoperative delirium occurs in around 25% of elderly patients within a week of surgery. It is a transient mental dysfunction that can result in increased morbidity, delayed functional recovery and prolonged hospital stay. The distinguishing features are impaired cognition, fluctuating levels of consciousness and altered psychomotor activity. It is usually seen within a couple of days post-operation and is often worse at night. It may go unnoticed or be misdiagnosed. Patients are usually incoherent, disorientated and have impairment of memory and attention. It ranges from mild confusion to full hallucinations. As in this scenario, patients with delirium may remove vital drains or temporary pacemaker wires, or they may fall and injure themselves when getting out of bed, and so need careful monitoring.
The Mini Mental State Exam (MMSE) is useful to monitor fluctuating cognitive functioning.
Preoperative risk factors include previous history of delirium, pre-existing dementia, age over 70 years, depression, polypharmacy and drug interaction, alcohol or sedative- hypnotic withdrawal, endocrine and metabolic problems. Peri-operative hypoxia, hypocarbia and sepsis are also risk factors as are certain anaesthetics, pethidine, and anticholinergics. The risk of postoperative delirium is similar with general and regional anaesthetic techniques. Regional anaesthesia may involve the use of drugs that increase the risk. Pre-existing sensory or perceptual deficits, fluid and electrolyte imbalance, sleep deprivation (for example, from a busy ward) and an inability to keep track of time can all contribute to confusion and disorientation.
The underlying organic cause of the delirium should be found and treated. If medication is necessary, antipsychotics (for example, haloperidol or the newer, atypical antipsychotics) are generally preferable to benzodiazepines. For acute control of delirium, oral haloperidol at a dose of 0.5 mg with a minimum interval of two hours is the preferred treatment. For more agitated patients, IM haloperidol can be used. The maximum total dose in 24 hours should not usually exceed 5 mg. For patients with Parkinson’s disease or Lewy body dementia an appropriate alternative is lorazepam 0.5–1 mg orally up to a maximum dose of 3 mg in 24 hours with a minimum interval of 2 hours between doses. After recovery from an acute episode, a psychiatric or psychosocial assessment may aid early functional rehabilitation.
Section 5 of the Mental Capacity Act is the legal framework under which treatment can be given to a patient who lacks capacity to consent to that treatment. The treatment must
• Give regular reassurance and reorientation.
• Use clear communication.
• Minimize noise and have adequate lighting (but not too bright).
• Use relaxation strategies such as music etc. Avoid unnecessary waking.
• Encourage familiar family or friends to stay.
• Keep consistent carers and avoid regular moves.
• Avoid restraint and use strategies to maintain oxygenation and mobility.
• Avoid invasive interventions if possible.
• Use medication only as last resort.
Nursing patients with delirium
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be necessary and in that person’s best interests. In this case the patient’s inability to retain the information necessary to make an informed decision about his care demonstrates lack of capacity. This should be carefully documented. This capacity assessment can be carried out by the treating surgeons. Restraint of a patient who lacks capacity is only allowed to prevent harm and provided that the restraint is proportionate to both the likelihood and the seriousness of that harm. Keeping this patient in hospital against his will to treat delirium will prevent him from suffering serious harm.
The Mental Health Act can only be used to assess or treat mental disorder. Although delirium can be construed as a mental disorder, and treatment of the underlying physical cause of the delirium can be considered treatment for the mental disorder of delirium, the Mental Capacity Act provides a much clearer framework for the delivery of care against a patient’s wishes under these circumstances.
• Postoperative delirium is common in the elderly.
• Nursing care is key.